Right Ventricular Pump Efficiency in Secundum-Type Atrial Septal Defect.

BACKGROUND: A well-functioning cardiopulmonary system, which works as a pump, should generate adequate stroke volume with as little stroke work as possible. We propose a new composite parameter, right ventricular (RV) pump efficiency (η) = left ventricular stroke volume / right ventricular stroke work, to describe this idea in a volume overload population with secundum-type atrial septal defect (ASD). METHODS: We consecutively enrolled 50 patients with secundum-type ASD to investigate the relationship between right-sided volume overload and RV pump efficiency. Sixteen patients with a pulmonary to systemic flow ratio (Qp/Qs) > 1.5 underwent implantation of an occluder. The paired t test was used to compare RV pump efficiency before and after ASD closure. RESULTS: RV pump efficiency was inversely correlated with Qp/Qs and was 60 ± 20‰ · mmHg-1 at Qp/Qs = 1. After ASD closure, RV volume, ejection fraction and free wall strain all significantly decreased, while RV pump efficiency significantly increased from 27.4 ± 13.6 to 63.9 ± 20.4‰ · mmHg-1. CONCLUSIONS: RV pump efficiency can superiorly reflect the chronicity and severity of secundum-type ASD.

Electrocardiography Score for Left Ventricular Systolic Dysfunction in Non-ST Segment Elevation Acute Coronary Syndrome.

Background: Few studies have characterized electrocardiography (ECG) patterns correlated with left ventricular (LV) systolic dysfunction in patients with non-ST segment elevation acute coronary syndrome (NSTE-ACS). Objectives: This study aims to develop ECG pattern-derived scores to predict LV systolic dysfunction in NSTE-ACS patients. Methods: A total of 466 patients with NSTE-ACS were retrospectively enrolled. LV ejection fraction (LVEF) was assessed by echocardiography within 72 h after the first triage ECG acquisition; there was no coronary intervention in between. ECG score was developed to predict LVEF < 40%. Performance of LVEF, the Global Registry of Acute Coronary Events (GRACE), Thrombolysis in Myocardial Infarction (TIMI) and ECG scores to predict 24-month all-cause mortality were analyzed. Subgroups with varying LVEF, GRACE and TIMI scores were stratified by ECG score to identify patients at high risk of mortality. Results: LVEF < 40% was present in 20% of patients. We developed the PQRST score by multivariate logistic regression, including poor R wave progression, QRS duration > 110 ms, heart rate > 100 beats per min, and ST-segment depression ≥ 1 mm in ≥ 2 contiguous leads, ranging from 0 to 6.5. The score had an area under the curve (AUC) of 0.824 in the derivation cohort and 0.899 in the validation cohort for discriminating LVEF < 40%. A PQRST score ≥ 3 could stratify high-risk patients with LVEF ≥ 40%, GRACE score > 140, or TIMI score ≥ 3 regarding 24-month all-cause mortality. Conclusions: The PQRST score could predict LVEF < 40% in NSTE-ACS patients and identify patients at high risk of mortality in the subgroups of patients with LVEF ≥ 40%, GRACE score > 140 or TIMI score ≥ 3.

Stepwise manipulation of cardiac computed tomography multi-planar reconstruction to mimic transesophageal echocardiography.

Cardiac computed tomography (CT) is increasingly used to plan transcatheter structural heart interventions. However, intraoperative guidance relies on transesophageal echocardiography (TEE) and fluoroscopy. This study sought to develop a stepwise CT multi-planar reconstruction manipulation method to mimic TEE, bridging the gap between preoperative planning and intraoperative guidance tools. This CT manipulation reproduced similar configurations as TEE views in the mid-esophageal left ventricle (LV) views, transgastric LV 2-chamber views for mitral apparatus, and other miscellaneous views. Stepwise cardiac CT manipulation to mimic TEE is the final piece of the puzzle in the mental co-registration of these three crucial imaging modalities. Now, we can predict the TEE images and fluoroscopy projections in a preoperative rehearsal, thus improving the intraoperative accuracy of interventions.

Sacubitril/valsartan in heart failure with reduced ejection fraction patients: Real world experience on advanced chronic kidney disease, hypotension, and dose escalation.

BACKGROUND: Angiotensin receptor and neprilysin inhibition (ARNI) has been shown to reduce cardiovascular mortality by 20% as compared with enalapril in a randomized controlled trial. However, there is a paucity of real-world data on the effects of ARNI in heart failure patients with reduced ejection fraction (HFrEF), especially those with concurrent renal impairment or hypotension. METHODS: Between 2016 and 2017, we recruited 466 HFrEF patients treated with sacubitril/valsartan (Group A) and 466 patients managed with standard HF treatment without ARNI (Group B) in a HF referral center. Baseline characteristics and clinical outcomes were collected between both groups. RESULTS: Baseline characteristics were comparable between the two groups. During a follow-up period of 15 months, death from cardiovascular causes or first unplanned hospitalization for HF occurred in 100 patients in Group A (21.5%) and 144 in Group B (30.9%, hazard ratio 0.66; 95% CI 0.51-0.85; p=0.001). The incidences of deaths from any causes, cardiovascular death, sudden death, and HF re-hospitalization were all significantly lower in Group A than Group B patients. Among patients with different chronic kidney disease stages and normotensive patients, treatment with sacubitril/valsartan showed more favorable outcomes than treatment with standard HF care without ARNI. However, in patients with baseline systolic blood pressure lower than 100mmHg, there were no significant differences of outcomes in both groups. Among Group A patients, escalation of sacubitril/valsartan was associated with better outcomes. CONCLUSIONS: Our study demonstrated the effectiveness of sacubitril/valsartan on HFrEF patients in real world practice, including those with advanced renal impairment.